Why the health crisis in “healthy” New Hampshire should generate a national policy conversation

February 5, 2016

In December, the latest America’s Health Rankings report identified New Hampshire as the fifth-healthiest state in the country. On multiple key indicators of health status at all stages of life—including rates of infant mortality, food insecurity, obesity, diabetes, hypertension, and longevity—New Hampshire fares better than the US average. Its decision to expand Medicaid under the Affordable Care Act (ACA) will further reduce the lower-than-average rates of uninsured residents.

Health in New Hampshire

Sources: CDC, Census, World Life Expectancy, State of Obesity.

But New Hampshire’s status as a health leader is being seriously jeopardized by another top-five distinction: it’s one of the states most severely affected by the burgeoning US opioid epidemic. In 2014, New Hampshire ranked third (behind West Virginia and New Mexico) in the rate of drug-related overdose deaths. For every 100,000 people, there were 26.2 deaths in New Hampshire, almost double the national age-adjusted average. And the national picture isn’t exactly rosy: since 2000, the rate of deaths from drug overdoses has increased 137 percent. The rate of overdose deaths involving opioids (including abuse of prescription opioid drugs and heroin) has jumped 200 percent.

Candidates visiting New Hampshire during the run up to the February 9 primary have confronted the extraordinary reach of the epidemic across the state. But despite the outsized influence of New Hampshire in the presidential primary process, the discussions during campaign season have yet to morph into a meaningful national conversation.

What will it really take to slow, let alone reverse, this public health crisis?

At the heart of the matter is the imperative to treat the addiction already embedded in the population. New Hampshire continues to scramble to build its capacity to meet the ferocity of addiction with an equal measure of power.

  • A 2014 report found that there are not enough providers or programs to meet the current need for substance abuse treatment. That shortage includes medication management frequently required to deal with the biological ramifications of opioid addiction. Indeed, substance abuse treatment capacity across the United States has historically been inadequate, leaving many areas ill-equipped to deal with growing need.
  • Opioid addiction is a notoriously chronic disease with a complex intersection of medical and nonmedical factors. Only a small minority of providers offer recovery support services, such as relapse prevention management. Social supports like sober and supportive housing, employment services, transportation, and child care are also critical to help those struggling to beat addiction reestablish their lives. Although research demonstrates the importance of recovery support, payment for and availability of these services in the United States is erratic at best.
  • Until 2014, New Hampshire’s Medicaid program did not cover substance abuse treatment. But because the state chose to expand Medicaid under the ACA in August 2014, it was required to offer essential mental health and substance abuse services to the newly covered group. This group has since enrolled with qualified health plans on New Hampshire's federally facilitated marketplace where these benefits are also mandatory. Beginning in July 2016, New Hampshire will cover substance abuse services for adults who remain in the state's traditional Medicaid program. In the 19 states that have not yet opted to expand Medicaid, coverage is typically limited for adults without children, and coverage for substance abuse services is optional and can be more restrictive.
  • In January 2016, Governor Maggie Hassan announced approval of a Medicaid waiver that will bring up to $150 million in federal matching funds to help transform the behavioral health delivery system in the state over five years.

On February 9, the voters of New Hampshire will make a significant mark on the trajectories of presidential hopefuls. Unfortunately, the struggle to combat the opioid epidemic will extend long after that contest concludes. The acute need for more treatment capacity is an urgent concern for affected individuals, families, and health care providers. It is also a growing priority for the criminal justice system in many communities, as law enforcement and courts explore more opportunities for diversion to treatment.

Communities further along the campaign trail may or may not follow New Hampshire’s lead in picking candidates. But they should take up the conversation started in the “Live Free or Die” state and press the remaining candidates to address the public health crisis unfolding in the midst of the nation’s first 2016 primary. 

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